In 2023, chiropractic services are required to be closely aligned with the patient’s condition and should only be billed when deemed reasonably and medically necessary.

It’s important to note that billing is restricted to direct services provided directly to patients. Services rendered by the patient, unskilled assistants, or office technicians without the supervision of a licensed provider will not be considered as professional therapy.

A significant portion of the updated or revised billing codes for chiropractic focuses on simplifying the language used for evaluation/management (E/M) codes in various healthcare settings, including:

• Inpatient and observation care services
• Consultations
• Emergency department services
• Nursing facilities
• Home and residence services
• Prolonged services.

One of the common reasons chiropractic claims may be denied or rejected is for missing modifiers, misplaced modifiers, or invalid modifier combinations. Modifiers are added to Current Procedural Terminology (CPT®) codes to provide additional information required for processing a claim. To make everything more complicated, insurance companies and Medicare have set rules on how to use modifiers with specific chiropractic therapy CPT codes.

Modifier CPT codes serve to notify the insurance company that the services provided deviated slightly from what the CPT code specifies. It is crucial to include the appropriate modifier if your chosen CPT code requires one; failure to do so might result in your claim being rejected by the insurance company.

Not all chiropractic modifiers can be used with chiropractic procedure codes. Some modifier CPT codes are classified as payment modifiers that decide how much you will be paid for the service. Some modifiers used with CPT codes serve as informational modfiers to provide details on why two services, usually bundled together, should be considered as separate billable services.

Often in chiropractic clinics, confusion regarding the proper use of modifiers with chiropractic CPT codes could result in claim denials. Misusing chiropractic billing modifiers could also trigger an audit, leading to hefty fines. In this blog, we will discuss the most commonly misused chiropractic modifiers and how you can avoid making the same mistakes.

Commonly Misused  Modifiers in Chiropractic Claims

1. Modifier 59

Modifier 59 is probably the most over-utilized modifier. 59 is used to signify that a chiropractic procedure or service is independent of other codes and needs to be paid separately. A good example of when to use modifier 59 would be chiropractic CPT code 97012 (mechanical traction) and CPT code 97140 (manual therapy). If these two treatments were performed on the same date of service, the modifier 59 would be appended to 97140 on the claim form.

Modifier 59 Examples – Do’s and Dont’s

• Don’t use modifier 59 on an E/M service. If you want to report a separate and distinct E/M service with a non-E/M service performed on the same date, use modifier 25.
• Don’t report two chiropractic procedure codes of a code pair edit with a modifier 59 when they’re performed at the same anatomic site and same patient encounter. If you perform 2 procedures at separate anatomic sites or at separate patient encounters on the same date of service, you may use modifier 59 with CPT codes.
• If you don’t provide proper documentation for distinct procedural services, your claim might get denied. Your documentation justifies your billing decisions. Documentation must support a different session, different procedure, and different site, not ordinarily encountered or performed on the same day by the same individual.

In some instances, with some insurance companies, it is advisable to use X modifiers instead of the modifier 59. Effective January 1, 2015, XE, XS, XP, and XU are valid modifiers. These modifiers give greater reporting specificity in situations where you used modifier 59 previously. X subset modifiers may be appropriate to use with chiropractic CPT codes for billing when:

• It’s a separate encounter – Use XE
• It’s a separate structure – Use XS
• It’s a separate practitioner – Use XP
• It’s an unusual non-overlapping service – Use XE

Note: Like modifier 59, modifier XP should not be appended to an E/M service procedure code; this is not a valid or appropriate procedure/modifier combination.

2. Modifier AT

According to the Billing and Coding Guidelines for Chiropractic Services by CMS, the Acute Treatment (AT) modifier shall be used only when chiropractors bill for active/corrective treatment for Medicare purposes. The AT modifier must not be placed on the claim when maintenance therapy has been provided. Claims without the AT modifier will be considered maintenance therapy and denied.

Mistakes to avoid when using Modifier AT 

• Don’t forget to add Acute Treatment (AT) modifier on every claim containing common chiropractic CPT codes like 98940, 98941, and 98942, if active/corrective treatment is being performed. Note: CPT code 98943 is not reimbursed by Medicare.
• Don’t forget to mention the precise level of subluxation in the patient documentation. The document must support the active nature of the treatment when this modifier is submitted.
• Modifier AT should not be submitted, on the same detail line, with the modifier GA. GA modifier is the ‘Waiver of Liability Statement Issued as Required by Payer Policy.’ The modifier GA indicates that an ABN (Advanced Beneficiary Notice) is on file and allows the provider to bill the patient if not covered by Medicare. The use of this modifier ensures that upon denial, Medicare will automatically assign the beneficiary liability.

3. Modifier 25

If you’re billing E/M twice during the same day, you must add the modifier code 25. According to the American Chiropractic Association (ACA), use this modifier with chiropractic billing codes when there is a:

• New condition or injury in an existing patient
• New patient at your practice
• Re-evaluation to change treatment plans

Mistakes to avoid when using Modifier 25

• Don’t forget to add all applicable chiropractic ICD-10 codes that indicate the need for additional E/M services. In such cases, even if you added modifier 25 to a chiropractic CPT code, the claim will be denied.
• Don’t append modifier 25 to the procedure code. Modifier 25 is used only with evaluation and management (E&M) codes.
• Don’t add modifier 25 to the E/M code each time a minor procedure is performed in a facility. Many providers wrongly believe that evaluating the condition and deciding to perform a minor procedure makes them eligible to report an E&M service on the same day as the procedure. This is incorrect. Minor procedures already include E&M elements.
• Use modifier 25 only when services are performed over and above what is typical for the procedure. The documentation must report specific criteria for modifier 25 to be reported in a claim, such as – ‘Was this a new injury or exacerbation?’, ‘Did the symptoms improve or worsen?’, ‘Did you change the treatment plan or goal after examining the patient?’. The documentation must show that the extended E/M work was medically necessary.

4. Modifier LT & RT

Right Side (RT) and Left Side (LT) are location modifier CPT codes that identify where a procedure was performed. LT and RT modifiers are commonly used with the L3020 code which is for ‘Custom fabricated foot, insert, removable, molded to patient model, longitudinal/ metatarsal support, each.

Mistakes to avoid when using Modifiers RT and LT

For instance, a chiropractic provider bills 2 units of L3020. But the claim will be denied. Why? For not using the right modifiers.

Instead of submitting two units of the L3020 to indicate that the patient has one orthotic for each foot, you must use modifiers RT and LT for identifying the left foot and right foot. So the correct coding for this would take 2 line items of data entry:

• L3020-RT
• L3020-LT

However, in some instances, insurance companies like Blue Cross/Blue Shield of Illinois (BCBSIL) deny claims for foot orthotics. BCBIL denies claims when: 

1. Orthotics are created from a digital scanner.
2. It is NOT mentioned in the document that the patient has tried a number of alternatives, conservative treatments that have failed in order for the orthotic to qualify as “medically necessary.” Not all insurance companies accept custom-made orthotics (L3020). It’s important to check with your insurance companies and their reimbursement policies before making any claim submission.

Conclusion

The use of correct chiropractic billing modifiers 59, 25, AT, LT and RT is a critical element in medical billing. Providers need to scrutinize their claims and documentation to ensure that the modifiers they have used in a claim have not been misused. Knowing how to prevent rejections and denials in the first place and paying close attention to using chiropractic modifier codes correctly is the best solution to receiving revenue quicker.

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